Risk of brain metastases in patients with nonmetastatic lung cancer: Analysis of the Metropolitan Detroit Surveillance, Epidemiology, and End Results (SEER) data

Incidence of brain metastasis according to patient race and primary cancer origin: a systematic review

PURPOSE

A systematic review was conducted to investigate differences in incidence and primary origin of synchronous brain metastasis (sBM) in varying racial groups with different primary cancers.

METHODS

Adhering to PRISMA 2020 guidelines a search was conducted using PubMed and Ovid databases for publications from January 2000 to January 2023, with search terms including combinations of "brain metastasis," "race," "ethnicity," and "incidence." Three independent reviewers screened for inclusion criteria encompassing studies clearly reporting primary cancer sites, patient demographics including race, and synchronous BM (sBM) incidence.

RESULTS

Of 806 articles, 10 studies comprised of mainly adult patients from the United States met final inclusion for data analysis. Higher sBM incidence proportions were observed in American Indian/Alaska native patients for primary breast (p < 0.001), colorectal (p = 0.015), and esophageal cancers (p = 0.024) as well as in Asian or Pacific islanders for primary stomach (p < 0.001), thyroid (p = 0.006), and lung/bronchus cancers (p < 0.001) yet higher proportions in White patients for malignant melanoma (p < 0.001). Compared to White patients, Black patients had higher sBM incidence likelihood in breast cancer (OR = 1.27, p = 0.01) but lower likelihood in renal (OR = 0.46, p < 0.001) and esophageal cancers (OR = 0.31, p = 0.005). American Indian/Alaska native patients had a higher sBM likelihood (OR = 3.78, p = 0.004) relative to White patients in esophageal cancer.

CONCLUSIONS

These findings reveal several comparative racial differences in sBM incidence arising from different primary cancer origins, underscoring a need for further research to explain these variations. Identifying the factors contributing to these disparities holds the potential to promote greater equity in oncological care according to cancer type.

Potential of radiomics analysis and machine learning for predicting brain metastasis in newly diagnosed lung cancer patients

AIM

To explore the potential of utilising radiomics analysis and machine-learning models that incorporate intratumoural and peritumoural regions of interest (ROIs) for predicting brain metastasis (BM) in newly diagnosed lung cancer patients.

MATERIALS AND METHODS

The study comprised 183 lung cancer patients (training cohort: n=146; validation cohort: n=37) whose radiomics features were extracted from plain computed tomography (CT) images of the primary lesion. Four machine-learning algorithms (logistic regression [LR], support vector machine [SVM], k-nearest neighbour algorithm [KNN], and random forest [RF]) were employed to develop predictive models. Model diagnostic performance was assessed through receiver operating characteristic (ROC) analysis, and clinical utility was evaluated using decision curve analysis (DCA). Finally, the radiomics model's generalisation ability was further validated in the prediction of metachronous brain metastasis (MBM).

RESULTS

After feature screening, 22 radiomics features were identified as highly predictive, of which nine were derived from the peritumour region. All four machine-learning models demonstrated predictive capability, with SVM showing superior efficiency and robustness. The area under the ROC curve (AUC) of SVM was 0.918 in the training cohort and 0.901 in the validation cohort. DCA indicated the highest net benefit. Furthermore, the time-dependent ROC curve exhibited predictive efficacy for MBM occurrence across 1-, 2-, and 3-year follow-up periods, with all AUC values exceeding 0.7.

CONCLUSION

The optimal SVM model integrating intratumoural and peritumoural radiomics features was confirmed and defined as an imaging biomarker for predicting BM in newly diagnosed lung cancer patients, underscoring its potential to significantly impact clinical diagnosis and treatment.

Clinicopathological characteristics and prognosis of synchronous brain metastases from non-small cell lung cancer compared with metachronous brain metastases

Purpose

Brain metastasis (BM) from non-small cell lung cancer (NSCLC) is a serious complication severely affecting patients' prognoses. We aimed to compare the clinicopathological features and prognosis of synchronous and metachronous BM from NSCLC.

Methods

Clinical data of 461 patients with brain metastases from NSCLC who visited the Cancer Hospital of China Medical University from 2005 to 2017 were retrospectively collected. We analyzed the pathophysiological characteristics of synchronous and metachronous BM from NSCLC and survival rates of the patients. Propensity score matching analysis was used to reduce bias between groups. In addition, we used the Kaplan-Meier method for survival analysis, log-rank test to compare survival rates, and Cox proportional hazards regression model for multivariate prognosis analysis.

Results

Among 461 patients with BM, the number of people who met the inclusion criteria was 400 cases, and after 1:2 propensity score matching,130 had synchronous BM and 260 had metachronous BM. The survival time was longer for metachronous BM in driver mutation-negative patients with squamous cell carcinoma than synchronous BM. Conversely, metachronous and synchronous BM with gene mutations and adenocarcinoma showed no differences in survival time. Multivariate analysis showed that metachronous BM was an independent prognostic factor for overall survival. Furthermore, the pathological type squamous cell carcinoma and Karnofsky Performance Status score <80 were independent risk factors affecting overall survival.

Conclusion

BM status is an independent factor influencing patient outcome. Moreover, synchronous and metachronous BM from NSCLC differ in gene mutation profile, pathological type, and disease progression and hence require different treatments.

A Review of Recent Advances in the Molecular Mechanisms Underlying Brain Metastasis in Lung Cancer

Brain metastasis from lung cancer is a prevalent mode of treatment failure associated with a poor prognosis. The incidence of brain metastasis has recently shown a dramatic increase. The early detection and risk stratification of lung cancer-related brain metastasis would be highly advantageous for patients. However, our current knowledge and comprehension of the underlying mechanisms driving brain metastasis in lung cancer pose significant challenges. This review summarizes the mechanisms underlying brain metastasis, focusing on the intricate interplay between lung cancer-derived tumor cells and the unique characteristics of the brain, recent advancements in the identification of driver genes, concomitant genes, epigenetic features, including miRNAs and long noncoding RNAs, as well as the molecular characterization of brain metastasis originating from other organs, which may further enhance risk stratification and facilitate precise treatment strategies.

Distinguishing EGFR mutation molecular subtypes based on MRI radiomics features of lung adenocarcinoma brain metastases

OBJECTIVE

To explore the feasibility of identifying epidermal growth factor receptor (EGFR) mutation molecular subtypes in primary lesions based on the radiomics features of lung adenocarcinoma brain metastases using magnetic resonance imaging (MRI).

METHODS

We retrospectively analyzed clinical, imaging, and genetic testing data of patients with lung adenocarcinoma with EGFR gene mutations who had brain metastases. Three-dimensional radiomics features were extracted from contrast-enhanced T1-weighted images. The volume of interest was delineated and normalized using Z-score, dimensionality reduction was performed using principal component analysis, feature selection using Relief, and radiomics model construction using adaptive boosting as a classifier. Data were randomly divided into training and testing datasets at an 8:2 ratio. Five-fold cross-validation was conducted in the training set to select the optimal radiomics features and establish a predictive model for distinguishing between exon 19 deletion (19Del) and exon 21 L858R point mutation (21L858R), the two most common EGFR gene mutations. The testing set was used for external validation of the models. Model performance was evaluated using receiver operating characteristic curve and decision curve analyses.

RESULTS

Overall, 86 patients with 228 brain metastases were included. Patient age was identified as an independent predictor for distinguishing between 19Del and 21L858R. The area under the curve (AUC) values of the radiomics model in the training and testing datasets were 0.895 (95% confidence interval [CI]: 0.850-0.939) and 0.759 (95% CI: 0.0.614-0.903), respectively. The AUC for diagnosis of all cases using a combined model of age and radiomics was 0.888 (95% CI: 0.846-0.930), slightly higher than that of the radiomics model alone (0.866, 95% CI: 0.820-0.913), but without statistical significance (p=0.1626). In the decision curve analysis, both models demonstrated clinical net benefits.

CONCLUSIONS

The radiomics model based on MRI of lung adenocarcinoma brain metastases could distinguish between EGFR 19Del and 21L858R mutations in the primary lesion.

Synchronous versus metachronous spinal metastasis: a comparative study of survival outcomes following neurosurgical treatment

PURPOSE

Patients with spinal metastases (SM) from solid neoplasms typically exhibit progression to an advanced cancer stage. Such metastases can either develop concurrently with an existing cancer diagnosis (termed metachronous SM) or emerge as the initial indication of an undiagnosed malignancy (referred to as synchronous SM). The present study investigates the prognostic implications of synchronous compared to metachronous SM following surgical resection.

METHODS

From 2015 to 2020, a total of 211 individuals underwent surgical intervention for SM at our neuro-oncology facility. We conducted a survival analysis starting from the date of the neurosurgical procedure, comparing those diagnosed with synchronous SM against those with metachronous SM.

RESULTS

The predominant primary tumor types included lung cancer (23%), prostate cancer (21%), and breast cancer (11.3%). Of the participants, 97 (46%) had synchronous SM, while 114 (54%) had metachronous SM. The median overall survival post-surgery for those with synchronous SM was 13.5 months (95% confidence interval (CI) 6.1-15.8) compared to 13 months (95% CI 7.7-14.2) for those with metachronous SM (p = 0.74).

CONCLUSIONS

Our findings suggest that the timing of SM diagnosis (synchronous versus metachronous) does not significantly affect survival outcomes following neurosurgical treatment for SM. These results support the consideration of neurosurgical procedures regardless of the temporal pattern of SM manifestation.

Harnessing immunotherapy for brain metastases: insights into tumor-brain microenvironment interactions and emerging treatment modalities

Brain metastases signify a deleterious milestone in the progression of several advanced cancers, predominantly originating from lung, breast and melanoma malignancies, with a median survival timeframe nearing six months. Existing therapeutic regimens yield suboptimal outcomes; however, burgeoning insights into the tumor microenvironment, particularly the immunosuppressive milieu engendered by tumor-brain interplay, posit immunotherapy as a promising avenue for ameliorating brain metastases. In this review, we meticulously delineate the research advancements concerning the microenvironment of brain metastases, striving to elucidate the panorama of their onset and evolution. We encapsulate three emergent immunotherapeutic strategies, namely immune checkpoint inhibition, chimeric antigen receptor (CAR) T cell transplantation and glial cell-targeted immunoenhancement. We underscore the imperative of aligning immunotherapy development with in-depth understanding of the tumor microenvironment and engendering innovative delivery platforms. Moreover, the integration with established or avant-garde physical methodologies and localized applications warrants consideration in the prevailing therapeutic schema.

Adding simultaneous integrated boost to whole brain radiation therapy improved intracranial tumour control and minimize radiation-induced brain injury risk for the treatment of brain metastases

BACKGROUND

Brain metastases (BMs) are the most frequent intracranial tumours associated with poor clinical outcomes. Radiotherapy is essential in the treatment of these tumours, although the optimal radiation strategy remains controversial. The present study aimed to assess whether whole brain radiation therapy with a simultaneous integrated boost (WBRT + SIB) provides any therapeutic benefit over WBRT alone.

METHODS

We included and retrospectively analysed 82 patients who received WBRT + SIB and 83 who received WBRT alone between January 2012 and June 2021. Intracranial progression-free survival (PFS), local tumour control (LTC), overall survival (OS), and toxicity were compared between the groups.

RESULTS

Compared to WBRT alone, WBRT + SIB improved intracranial LTC and PFS, especially in the lung cancer subgroup. Patients with high graded prognostic assessment score or well-controlled extracranial disease receiving WBRT + SIB had improved intracranial PFS and LTC. Moreover, WBRT + SIB also improved the long-term intracranial tumour control of small cell lung cancer patients. When evaluating toxicity, we found that WBRT + SIB might slightly increase the risk of radiation-induced brain injury, and that the risk increased with increasing dosage. However, low-dose WBRT + SIB had a tolerable radiation-induced brain injury risk, which was lower than that in the high-dose group, while it was comparable to that in the WBRT group.

CONCLUSIONS

WBRT + SIB can be an efficient therapeutic option for patients with BMs, and is associated with improved intracranial LTC and PFS. Furthermore, low-dose WBRT + SIB (biologically effective dose [BED] ≤ 56 Gy) was recommended, based on the acceptable risk of radiation-induced brain injury and satisfactory tumour control.

TRIAL REGISTRATION

Retrospectively registered.

The Impact of Time Interval on Prognosis in Patients with Non-Small Cell Lung Cancer Brain Metastases After Metastases Surgery

BACKGROUND

Non-small cell lung cancer (NSCLC) is a prominent malignancy often linked to the development of brain metastases (BM), which commonly appear at diverse time intervals (TI) following the lung cancer diagnosis. This study endeavors to determine the prognostic significance of the time interval in patients with NSCLC who undergo BM surgery. Through this investigation, we aim to improve our understanding of the factors impacting the prognosis of BM cases originating from NSCLC.

METHODS

We analyzed data from 74 patients (2011-2021) who underwent BM surgery at our institution. The relationship between various clinical, radiological, and histopathological factors, as well as TI and overall survival (OS), was examined.

RESULTS

The median TI from initial NSCLC diagnosis to BM surgery was 19 months (range: 9-36 months). Notably, a shorter TI of less than 23 months was found to be independently associated with postoperative survival (adjusted odds ratio [aOR] 2.87, 95% confidence interval [CI] 1.03-8.02, P = 0.045). Additionally, a shorter TI was independently correlated with the absence of adjuvant chemotherapy for NSCLC (aOR 0.25, 95% CI 0.07-0.83, P = 0.023) and lack of targeted therapy (aOR 0.02, 95% CI 0.00-0.16, P < 0.001). Late-onset BM (TI ≥ 36 months) was observed in 15 cases (20.3%), in this subgroup, patients aged 60 years or older at the time of lung cancer diagnosis exhibited a significant independent correlation with late-onset BM (aOR 7.24, 95% CI 1.59-32.95, P = 0.011). NSCLC patients who underwent adjuvant chemotherapy displayed a notable correlation with late-onset BM (aOR 6.46, 95% CI 1.52-27.43, P = 0.011), while those who received targeted therapy also exhibited an independent association (aOR 2.27, 95% CI 1.70-3.03, P < 0.001).

CONCLUSIONS

Multiple factors contribute to the variability in the onset interval of BM subsequent to NSCLC diagnosis. The occurrence of BM within TI < 23 months following the initial diagnosis of NSCLC was demonstrated as an independent factor associated with an unfavorable prognosis following BM surgery. Furthermore, patients with NSCLC who did not receive adjuvant chemotherapy and lacked targeted therapy were shown to have an elevated likelihood of developing BM after a long progression-free survival.

Treatment and survival of patients with small cell lung cancer and brain metastasis

PURPOSE

To elucidate treatment patterns and their outcomes in patients with small cell lung cancer (SCLC) and brain metastasis (BM).

METHODS

In this retrospective study, patients with SCLC and BM were stratified by treatment modality into three groups: those treated with systemic therapy only, those treated with stereotactic radiosurgery (SRS) and systemic therapy, and those treated with whole-brain radiotherapy (WBRT) and systemic therapy. The primary outcomes were overall survival (OS) and time to central nervous system progression (TTCP).

RESULTS

The analysis included 149 patients. After BM diagnosis, 48 patients (32.2%) received systemic therapy alone, 33 received SRS with systemic therapy, and 68 received WBRT with systemic therapy. The median OS and TTCP were 7.2 months and 8.7 months, respectively. Patients receiving WBRT with systemic therapy exhibited better intracranial control, but not better OS, than did the other patients. Key prognostic factors affecting OS were age, BM lesion count, chemotherapy, and immunotherapy. Notably, the Eastern Cooperative Oncology Group performance status and BM lesion count significantly influenced intracranial control in patients treated with SRS and systemic therapy.

CONCLUSION

Although WBRT combined with systemic therapy offer better intracranial control in patients with SCLC and BM, this approach is not superior to the other approaches in terms of OS benefits. Emerging systemic therapies, such as immunotherapy, may be used as alternative or adjunctive treatments for specific patient populations. Further studies are warranted to refine treatment selection.

Comparison of first-line radiosurgery for small-cell and non-small cell lung cancer brain metastases (CROSS-FIRE)

INTRODUCTION

Historical reservations regarding stereotactic radiosurgery (SRS) for small-cell lung cancer (SCLC) brain metastases include concerns for short-interval and diffuse central nervous system (CNS) progression, poor prognoses, and increased neurological mortality specific to SCLC histology. We compared SRS outcomes for SCLC and non-small cell lung cancer (NSCLC) where SRS is well established.

METHODS

Multicenter first-line SRS outcomes for SCLC and NSCLC from 2000 to 2022 were retrospectively collected (n = 892 SCLC, n = 4785 NSCLC). Data from the prospective Japanese Leksell Gamma Knife Society (JLGK0901) clinical trial of first-line SRS were analyzed as a comparison cohort (n = 98 SCLC, n = 814 NSCLC). Overall survival (OS) and CNS progression were analyzed using Cox proportional hazard and Fine-Gray models, respectively, with multivariable adjustment for cofactors including age, sex, performance status, year, extracranial disease status, and brain metastasis number and volume. Mutation-stratified analyses were performed in propensity score-matched retrospective cohorts of epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) positive NSCLC, mutation-negative NSCLC, and SCLC.

RESULTS

OS was superior for patients with NSCLC compared to SCLC in the retrospective dataset (median OS = 10.5 vs 8.6 months; P < .001) and in the JLGK0901 dataset. Hazard estimates for first CNS progression favoring NSCLC were similar in both datasets but reached statistical significance in the retrospective dataset only (multivariable hazard ratio = 0.82, 95% confidence interval = 0.73 to 0.92, P = .001). In the propensity score-matched cohorts, there were continued OS advantages for NSCLC patients (median OS = 23.7 [EGFR and ALK positive NSCLC] vs 13.6 [mutation-negative NSCLC] vs 10.4 months [SCLC], pairwise P values < 0.001), but no statistically significant differences in CNS progression were observed in the matched cohorts. Neurological mortality and number of lesions at CNS progression were similar for NSCLC and SCLC patients. Leptomeningeal progression was increased in patients with NSCLC compared to SCLC in the retrospective dataset only (multivariable hazard ratio = 1.61, 95% confidence interval = 1.14 to 2.26, P = .007).

CONCLUSIONS

After SRS, SCLC histology was associated with shorter OS compared to NSCLC. CNS progression occurred earlier in SCLC patients overall but was similar in patients matched on baseline factors. SCLC was not associated with increased neurological mortality, number of lesions at CNS progression, or leptomeningeal progression compared to NSCLC. These findings may better inform clinical expectations and individualized decision making regarding SRS for SCLC patients.

The development and validation of a nomogram for predicting brain metastases after chemotherapy and radiotherapy in male small cell lung cancer patients with stage III

OBJECTIVE

The purpose of this research was to develop a model for brain metastasis (BM) in limited-stage small cell lung cancer (LS-SCLC) patients and to help in the early identification of high-risk patients and the selection of individualized therapies.

METHODS

Univariate and multivariate logic regression was applied to identify the independent risk factors of BM. A receiver operating curve (ROC) and nomogram for predicting the incidence of BM were then conducted based on the independent risk factors. The decision curve analysis (DCA) was performed to assess the clinical benefit of prediction model.

RESULTS

Univariate regression analysis showed that the CCRT, RT dose, PNI, LLR, and dNLR were the significant factors for the incidence of BM. Multivariate analysis showed that CCRT, RT dose, and PNI were independent risk factors of BM and were included in the nomogram model. The ROC curves revealed the area under the ROC (AUC) of the model was 0.764 (95% CI, 0.658-0.869), which was much higher than individual variable alone. The calibration curve revealed favorable consistency between the observed probability and predicted probability for BM in LS-SCLC patients. Finally, the DCA demonstrated that the nomogram provides a satisfactory positive net benefit across the majority of threshold probabilities.

CONCLUSIONS

In general, we established and verified a nomogram model that combines clinical variables and nutritional index characteristics to predict the incidence of BM in male SCLC patients with stage III. Since the model has high reliability and clinical applicability, it can provide clinicians with theoretical guidance and treatment strategy making.

Risk factors and a new nomogram for predicting brain metastasis from lung cancer: a retrospective study

Objective

This study aims to establish and validate a new nomogram for predicting brain metastasis from lung cancer by integrating data.

Methods

266 patients diagnosed as lung cancer between 2016 and 2018 were collected from Guangdong Academy of Medical Sciences. The first 70% of patients were designated as the primary cohort and the remaining patients were identified as the internal validation cohort. Univariate and multivariable logistics regression were applied to analyze the risk factors. Independent risk factors were used to construct nomogram. C-index was used to evaluate the prediction effect of nomogram.100 patients diagnosed as lung cancer between 2018 and 2019 were collected for external validation cohorts. The evaluation of nomogram was carried out through the distinction and calibration in the internal validation cohort and external validation cohort.

Results

166 patients were diagnosed with brain metastasis among the 266 patients. The gender, pathological type (PAT), leukocyte count (LCC) and Fibrinogen stage (FibS) were independent risk factors of brain metastasis. A novel nomogram has been developed in this study showed an effective discriminative ability to predict the probability of lung cancer patients with brain metastasis, the C-index was 0.811.

Conclusion

Our research provides a novel model that can be used for predicting brain metastasis of lung cancer patients, thus providing more credible evidence for clinical decision-making.

Immune surveillance of brain metastatic cancer cells is mediated by IFITM1

Brain metastasis, most commonly originating from lung cancer, increases cancer morbidity and mortality. Although metastatic colonization is the rate-limiting and most complex step of the metastatic cascade, the underlying mechanisms are poorly understood. Here, in vivo genome-wide CRISPR-Cas9 screening revealed that loss of interferon-induced transmembrane protein 1 (IFITM1) promotes brain colonization of human lung cancer cells. Incipient brain metastatic cancer cells with high expression of IFITM1 secrete microglia-activating complement component 3 and enhance the cytolytic activity of CD8+ T cells by increasing the expression and membrane localization of major histocompatibility complex class I. After activation, microglia (of the innate immune system) and cytotoxic CD8+ T lymphocytes (of the adaptive immune system) were found to jointly eliminate cancer cells by releasing interferon-gamma and inducing phagocytosis and T-cell-mediated killing. In human cancer clinical trials, immune checkpoint blockade therapy response was significantly correlated with IFITM1 expression, and IFITM1 enhanced the brain metastasis suppression efficacy of PD-1 blockade in mice. Our results exemplify a novel mechanism through which metastatic cancer cells overcome the innate and adaptive immune responses to colonize the brain, and suggest that a combination therapy increasing IFITM1 expression in metastatic cells with PD-1 blockade may be a promising strategy to reduce metastasis.

Validation of the initial brain metastasis velocity in non-small cell lung cancer at a single cancer center

PURPOSE

The initial brain metastasis velocity (iBMV) was recently reported as a survival predictor after brain metastases (BM) in patients treated by stereotactic radiosurgery. In this study, we validated whether iBMV is a prognostic tool, regardless of treatment modality, in patients with non-small cell lung cancer (NSCLC) with metachronous BM.

METHODS

We retrospectively reviewed consecutive 3,792 new lung cancer cases in which no BM was found on magnetic resonance (MR) screening between February 2014 and December 2019, and enrolled 176 NSCLC patients with subsequent BM. Overall survival (OS) was calculated from the date of MR to identify the time from BM to death.

RESULTS

The median iBMV score was 1.9. We used an iBMV score of 2.0 as the cutoff level, as previously reported. An iBMV score ≥ 2.0 was significantly associated with older age, high neutrophil-to-lymphocyte ratio, and Stage IV (P = 0.04, 0.02, and 0.02, respectively). The median OS was 0.92 years. The median OS for patients with iBMV score ≥ 2.0 and < 2.0 were 0.59 years and 1.33 years, respectively (P < 0.001). Multivariate analysis showed that an iBMV score ≥ 2.0, ECOG performance status score of 1-3, Stage IV, and non-adenocarcinoma histology were independent poor prognostic factors (hazard ratio (HR), 1.94; P = 0.0001; HR, 1.53; P = 0.04; HR, 1.45; P = 0.04; and HR, 1.14; P = 0.03, respectively). Patients with iBMV scores of < 2.0 were more likely to undergo craniotomy or stereotactic irradiation.

CONCLUSIONS

An iBMV score ≥ 2.0 is an independent predictor of survival in NSCLC patients with metachronous BM, regardless of the treatment modality.

A new prognostic model for brain metastases of specific primary tumors with stereotactic radiotherapy

PURPOSE

Stereotactic radiotherapy (SRT) was widely used in brain metastases (BM), especially in oligometastases. It is imperative to develop a new prognostic score to predict the overall survival (OS) of brain metastases based on prognostic factors for specific primary tumors.

MATERIAL AND METHOD

One hundred and ninety-seven patients were involved in the training cohort to develop a new prognostic score to predict the overall survival (OS) of brain metastases for specific primary tumors. Independent prognostic factors were confirmed using a Cox regression model. The score was developed based on clinical prognostic factors of OS with Cox proportional hazards model. The result was validated in another cohort with 56 participants to evaluate the performance of the score.

RESULTS

One hundred and ninety-seven patients with 329 brain metastases received SRT. For NSCLC, the significant prognostic factors were extracranial metastases, target therapy and number of brain metastases. For gastrointestinal cancer, the significant prognostic factors were target therapy and number of brain metastases.

CONCLUSION

The prognostic factors scores were varied by the histologic types which can be used to efficiently stratify for selected patients with brain-metastasis.

Survival after resection of brain metastasis: impact of synchronous versus metachronous metastatic disease

PURPOSE

Patients with brain metastasis (BM) from solid tumors are in an advanced stage of cancer. BM may occur during a known oncological disease (metachronous BM) or be the primary manifestation of previously unknown cancer (synchronous BM). The time of diagnosis might decisively impact patient prognosis and further treatment stratification. In the present study, we analyzed the prognostic impact of synchronous versus (vs.) metachronous BM occurrence following resection of BM.

METHODS

Between 2013 and 2018, 353 patients had undergone surgical therapy for BM at the authors' neuro-oncological center. Survival stratification calculated from the day of neurosurgical resection was performed for synchronous vs. metachronous BM diagnosis.

RESULTS

Non-small-cell lung carcinoma (NSCLC) was the most common tumor entity of primary site (43%) followed by gastrointestinal cancer (14%) and breast cancer (13%). Synchronous BM occurrence was present in 116 of 353 patients (33%), metachronous BM occurrence was present in 237 of 353 patients (67%). NSCLC was significantly more often diagnosed via resection of the BM (56% synchronous vs. 44% metachronous situation, p = 0.0001). The median overall survival for patients with synchronous BM diagnosis was 12 months (95% confidence interval (CI) 7.5-16.5) compared to 13 months (95% CI 9.6-16.4) for patients with metachronous BM diagnosis (p = 0.97).

CONCLUSIONS

The present study indicates that time of BM diagnosis (synchronous vs. metachronous) does not significantly impact patient survival following surgical therapy of BM. These results suggest that the indication for neurosurgical BM resection should be made regardless of a synchronous or a metachronous time of BM occurrence.

Metastatic Lesions of the Brain and Spine

Brain and spinal metastases are common in cancer patients and are associated with significant morbidity and mortality. Continued advancement in the systemic care of cancer has increased the life expectancy of patients, and consequently, the incidence of brain and spine metastasis has increased. There has been an increase in the understanding of oncogenic mutations, and research has also demonstrated spatial and temporal mutations in patients that may drive overall treatment resistance and failure. Combinatory treatments with radiation, surgery, and newer systemic therapies have continued to increase the life expectancy of patients with brain and spine metastases. Given the overall complexity of brain and spine metastases, this chapter aims to give a comprehensive overview and cover important topics concerning brain and spine metastases. This will include the molecular, genetic, radiographic, surgical, and non-surgical treatments of brain and spinal metastases.

Brain metastasis screening in the molecular age

The incidence of brain metastases (BM) amongst cancer patients has been increasing due to improvements in therapeutic options and an increase in overall survival. Molecular characterization of tumors has provided insights into the biology and oncogenic drivers of BM and molecular subtype-based screening. Though there are currently some screening and surveillance guidelines for BM, they remain limited. In this comprehensive review, we review and present epidemiological data on BM, their molecular characterization, and current screening guidelines. The molecular subtypes with the highest BM incidence are epithelial growth factor receptor-mutated non-small cell lung cancer (NSCLC), BRCA1, triple-negative (TN), and HER2+ breast cancers, and BRAF-mutated melanoma. Furthermore, BMs are more likely to present asymptomatically at diagnosis in oncogene-addicted NSCLC and BRAF-mutated melanoma. European screening standards recommend more frequent screening for oncogene-addicted NSCLC patients, and clinical trials are investigating screening for BM in hormone receptor+, HER2+, and TN breast cancers. However, more work is needed to determine optimal screening guidelines for other primary cancer molecular subtypes. With the advent of personalized medicine, molecular characterization of tumors has revolutionized the landscape of cancer treatment and prognostication. Incorporating molecular characterization into BM screening guidelines may allow physicians to better identify patients at high risk for BM development and improve patient outcomes.

Radiobiological evaluation considering the treatment time with stereotactic radiosurgery for brain metastases

Objective

We evaluated the radiobiological effect of the irradiation time with the interruption time of stereotactic radiosurgery (SRS) using CyberKnife® (CK) systemfor brain metastases.

Methods

We used the DICOM data and irradiation log file of the 10 patients with brain metastases from non-small-cell lung cancer (NSCLC) who underwent brain SRS. We defined the treatment time as the sum of the dose-delivery time and the interruption time during irradiations, and we used a microdosimetric kinetic model (MKM) to evaluate the radiobiological effects of the treatment time. The biological parameters, i.e. α0, β0, and the DNA repair constant rate (a + c), were acquired from NCI-H460 cell for the MKM. We calculated the radiobiological dose for the gross tumor volume (GTVbio) to evaluate the treatment time's effect compared with no treatment time as a reference. The D95 (%) and the Radiation Therapy Oncology Group conformity index (RCI) and Paddick conformity index (PCI) were calculated as dosimetric indices. We used several DNA repair constant rates (a + c) (0.46, 1.0, and 2.0) to assess the radiobiological effect by varying the DNA repair date (a + c) values.

Results

The mean values of D95 (%), RCI, and PCI for GTVbio were 98.8%, 0.90, and 0.80, respectively, and decreased with increasing treatment time. The mean values of D95 (%), RCI, and PCI of GTVbio at 2.0 (a+c) value were 94.9%, 0.71, and 0.49, respectively.

Conclusion

The radiobiological effect of the treatment time on tumors was accurately evaluated with brain SRS using CK.

Advances in knowledge

There has been no published investigation of the radiobiological impact of the longer treatment time with multiple interruptions of SRS using a CK on the target dose distribution in a comparison with the use of a linac. Radiobiological dose assessment that takes into account treatment time in the physical dose in this study may allow more accurate dose assessment in SRS for metastatic brain tumors using CK.

Predictive Model to Guide Brain Magnetic Resonance Imaging Surveillance in Patients With Metastatic Lung Cancer: Impact on Real-World Outcomes

PURPOSE

Brain metastasis is common in lung cancer, and treatment of brain metastasis can lead to significant morbidity. Although early detection of brain metastasis may improve outcomes, there are no prediction models to identify high-risk patients for brain magnetic resonance imaging (MRI) surveillance. Our goal is to develop a machine learning-based clinicogenomic prediction model to estimate patient-level brain metastasis risk.

METHODS

A penalized regression competing risk model was developed using 330 patients diagnosed with lung cancer between January 2014 and June 2019 and followed through June 2021 at Stanford HealthCare. The main outcome was time from the diagnosis of distant metastatic disease to the development of brain metastasis, death, or censoring.

RESULTS

Among the 330 patients, 84 (25%) developed brain metastasis over 627 person-years, with a 1-year cumulative brain metastasis incidence of 10.2% (95% CI, 6.8 to 13.6). Features selected for model inclusion were histology, cancer stage, age at diagnosis, primary site, and RB1 and ALK alterations. The prediction model yielded high discrimination (area under the curve 0.75). When the cohort was stratified by risk using a 1-year risk threshold of > 14.2% (85th percentile), the high-risk group had increased 1-year cumulative incidence of brain metastasis versus the low-risk group (30.8% v 6.1%, P < .01). Of 48 high-risk patients, 24 developed brain metastasis, and of these, 12 patients had brain metastasis detected more than 7 months after last brain MRI. Patients who missed this 7-month window had larger brain metastases (58% v 33% largest diameter > 10 mm; odds ratio, 2.80, CI, 0.51 to 13) versus those who had MRIs more frequently.

CONCLUSION

The proposed model can identify high-risk patients, who may benefit from more intensive brain MRI surveillance to reduce morbidity of subsequent treatment through early detection.

WDR5 is a prognostic biomarker of brain metastasis from non-small cell lung cancer

Background

Lung cancer (LC) is the most frequent caner type and causes the most cancer-related death. Brain metastases (BM) are the deadliest complications of lung cancer, and the prognostic biomarkers of BM are urgently needed.

Materials and methods

In our study, we established an inception cohort including 122 patients with asynchronous BM from NSCLC, and further selected 70 patients who received surgical resection, which compromised the validation cohort. With immunohistochemistry, we investigated the expression of WDR5 in the cohort. By chi-square method, the correlations between WDR5 and clinicopathological factors were analyzed. The prognostic indicators were analyzed with the univariate analysis, and independent prognostic factors were identified by multivariate analysis with Cox-regression model.

Results

WDR5 is frequently expressed in the cytoplasm of BM from NSCLC. Patients with low or high expression of WDR5 account for 60% and 40% respectively. High expression of WDR5 indicates poor prognosis of BM from NSCLC (P=0.001). In addition to WDR5, KPS is also a prognostic factor of BM, and high KPS predicts favorable prognosis (P=0.006). WDR5 is an independent prognostic biomarker for poor prognosis of BM from NSCLC, with the cancer-related odds as 2.48.

Conclusions

High expression of WDR5 can predict the poor prognosis of BM, and WDR5 is an independent prognostic biomarker of BM from NSCLC. Patients with WDR5 overexpression are more high-risk to suffer BM-related death and should receive more intense post-operational supervision.

A nomogram for predicting overall survival rate in patients with brain metastatic non-small cell lung cancer

The purpose was to develop a nomogram for the prediction of the 1- and 2-year overall survival (OS) rates in patients with brain metastatic non-small cell lung cancer (BMNSCLC). Patients were collected from the Surveillance Epidemiology and End Results program (SEER) and classified into the training and validation groups. Several independent prognostic factors identified by statistical methods were incorporated to establish a predictive nomogram. The concordance index (C-index), the area under the receiver operating characteristics curve (AUC), and calibration curve were applied to estimate predictive ability of the nomogram. To compare the clinical practicability of the nomogram and TNM staging system by decision curve analysis (DCA). A total of 24,164 eligible patients were collected and assigned into the training (n = 16,916) and validation groups (n = 7248). Based on the prognostic factors, we developed a nomogram with good discriminative ability. The C-indices for training and validation group were 0.727 and 0.728. The AUCs of 1- and 2-year OS rates were both 0.8, and the calibration curves also demonstrated good performance of the nomogram. DCA illustrated that the nomogram provided clinical net benefit compared with the TNM staging system. We developed a predictive nomogram for more accurate and comprehensive prediction of OS in BMNSCLC patients, which can be a useful and convenient tool for clinicians to make proper clinical decisions, and adjust follow-up management strategies.

Upregulation of XIAP promotes lung adenocarcinoma brain metastasis by modulating ceRNA network

Dysregulation of XIAP has been shown to affect the progression of a variety of cancers, including lung adenocarcinoma (LUAD). However, the function and mechanisms of XIAP in lung adenocarcinoma with brain metastasis (LUAD-BM) remains poorly understood. In this study, we analyzed the differential mRNA of 58 lung adenocarcinomas samples and 28 lung adenocarcinomas with brain metastases in GEO database. 191 differentially expressed mRNAs were significantly associated with immune response, the proliferation of the immune cell, cell-cell adhesion. Subsequent analyzed by lasso and SVM found that XIAP was significantly elevated in LUAD-BM and significantly associated with LUAD grade and metastasis. Then we constructed a molecular regulatory network of ncRNA-miRNA-mRNA ceRNA by Cystoscope based on the correlation obtained from Starbase. It was found that SBF2-AS1 or RUNDC3A-AS1, has-miR-338-3p and XIAP may have a regulatory relationship. Furthermore, we also initially found that XIAP was closely correlation with T cells, B cells, Mast cells, macrophages, and dendritic cells. In conclusion, we found that XIAP was significantly higher expressed in LUAD-BM compared with LUAD without brain metastasis, suggesting that XIAP may play an important role in the future prediction and clinical treatment of LUAD-BM.

Predictive value of clinical characteristics on risk and prognosis of synchronous brain metastases in small-cell lung cancer patients: A population-based study

BACKGROUND

Patients with small-cell lung cancer (SCLC) have a high incidence of synchronous brain metastases (SBM) and a poor prognosis, which causes a heavy burden of morbidity and mortality. A better understanding of the demographic and tumor-specific characteristics of these patients is critical to guiding clinical practice. The purpose of this study was to investigate the predictive and prognostic value of the clinical characteristics of SCLC patients with SBM at initial diagnosis.

METHODS

This is a retrospective study based on the data in the latest Surveillance, Epidemiology, and End Results (SEER) version which was released in 2021 for patients diagnosed with SCLC in the presence or absence of SBM from 2010 to 2018. Multivariable logistic regression was performed to identify predictors of the presence of SBM at the initial diagnosis. Kaplan-Meier curves and multivariable Cox regression models were built to compare the prognosis of patients with different clinical characteristics and treatments.

RESULTS

A total of 33,169 SCLC patients were enrolled in this study, including 5711 (17.2%) patients with SBM and 27,458 (82.8%) patients without SBM. Patients who are black(HR = 1.313, 95% CI = 1.167-1.478, p < 0.001), higher T stage (T2, HR = 1.193, 95%CI = 1.065-1.348, p = 0.005; T3, HR = 1.169, 95%CI = 1.029-1.327, p = 0.016; T4, HR = 1.259, 95%CI = 1.117-1.418, p < 0.001), lung metastases (HR = 1.434, 95%CI = 1.294-1.588, p < 0.001) and bone metastases (HR = 1.311, 95% CI = 1.205-1.426, p < 0.001) had greater odds of SBM at initial diagnosis. The median overall survival (OS) for SCLC patients with SBM was 5.0 months. Multivariable Cox regression revealed that age ≥ 65 (HR = 1.164, 95% CI = 1.086-1.247, p < 0.025), singled (HR = 1.095, 95% CI = 1.020-1.174, p = 0.012), higher T stage (T3, HR = 1.265, 95% CI = 1.123-1.425, p < 0.001; T4, HR = 1.192, 95% CI = 1.066-1.332, p = 0.002), higher N stage (N2, HR = 1.347, 95%CI = 1.214-1.494, p < 0.001; N3, HR = 1.452, 95%CI = 1.292-1.632, p < 0.001), liver metastases (HR = 1.415, 95%CI = 1.306-1.533, p < 0.001), and bone metastases (adjusted HR = 1.126, 95%CI = 1.039-1.221, p = 0.004). Analysis of treatment regimens showed that patients who received combinational treatment exhibited longer OS than chemotherapy or radiotherapy alone, and surgery combined with chemotherapy and radiotherapy exhibited the longest OS.

CONCLUSIONS

In this study, we identified risk factors for SBM in SCLC patients and prognostic indicators among this patient population. We also found that patients who received different therapeutic strategies exhibited significant difference on OS, which will provide evidence-based support for treatment options.

[Research Progress on Risk Factors of Brain Metastasis in Non-small Cell Lung Cancer]

Brain metastasis of non-small cell lung cancer (NSCLC) is a common treatment failure mode, and the median survival time of NSCLC patients with brain metastasis is only 1 mon-2 mon. Prophylactic cranial irradiation (PCI) can delay the occurrence of brain metastasis, but the survival benefits of NSCLC patients are still controversial. It is particularly important to identify the patients who are most likely to benefit from PCI. This article reviews the high risk factors of brain metastasis in NSCLC.
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Brain Metastases among Cancer Patients Diagnosed from 2010–2017 in Canada: Incidence Proportion at Diagnosis and Estimated Lifetime Incidence

The incidence of BM among Canadian cancer patients is unknown. We aimed to estimate IP of BM at the time of cancer diagnosis and during the lifetime of patients with selected primary cancers. Data on BM at diagnosis from 2010–2017 was obtained from the CCR. Site-specific IPs of BM were estimated from provincial registries containing ≥90% complete data on BM. The CCR IP estimates and the IP estimates from literature were applied to the total diagnosed primary cancers to estimate the number of concurrent BM and lifetime BM from 2010–2017 in Canada, respectively. The annual average number of patients with BM at diagnosis from all cancer sites was approximately 3227. The site-specific IPs of BM at diagnosis were: lung (9.42%; 95% CI: 9.16–9.68%), esophageal (1.58%; 95% CI: 1.15–2.02%), kidney/renal pelvis (1.33%; 95% CI: 1.12–1.54%), skin melanoma (0.73%; 95% CI: 0.61–0.84%), colorectal (0.22%; 95% CI: 0.18–0.26%), and breast (0.21%; 95% CI: 0.17–0.24%). Approximately 76,546 lifetime BM cases (or 5.70% of selected fifteen primary cancers sites) were estimated to have occurred from the 2010–2017 cancer patient cohort. These findings reflect results of population analyses in the US and Denmark. We recommend improved standardization of the collection of BM data within the CCR.

Managing Central Nervous System Spread of Lung Cancer: The State of the Art

Brain metastases (BrM) are common in both non-small-cell lung cancer and small-cell lung cancer. Substantial progress in BrM management has occurred in the past decade related to advances in both radiation and medical oncology. Recent and ongoing radiation trials have focused on increasing the candidacy for focal therapy of BrM with stereotactic radiosurgery; reducing the toxicity and improving patient selection for whole brain radiotherapy; and, in small-cell lung cancer, evaluating brain magnetic resonance imaging surveillance without prophylactic cranial irradiation, hippocampal avoidance in prophylactic cranial irradiation and whole brain radiotherapy, and the role of upfront stereotactic radiosurgery for BrM. In medical oncology, the development of multiple tyrosine kinase inhibitors with encouraging CNS activity and emerging data on the CNS activity of immune checkpoint inhibitors in some patients have opened the door to novel systemic and multidisciplinary treatment strategies for the management of BrM. Future research will focus on more robust characterizations of the CNS activity of targeted therapy and immunotherapies, as well as optimal integration and patient selection for multidisciplinary strategies involving CNS-active drugs, radiation therapy, and CNS surveillance.

The Risk of Hippocampal Metastasis and the Associated High-Risk Factors in 411 Patients With Brain Metastases

Background and Aims

To retrospectively analyze the incidence of hippocampal metastasis and the associated high-risk factors in patients with brain metastases and evaluate the safety of hippocampal avoidance whole-brain radiation therapy (HA-WBRT).

Methods

We retrospectively analyzed the data of patients with brain metastases diagnosed by contrast-enhanced cranial Magnetic resonance imaging (MRI) at the First Hospital of Lanzhou University from 2017 to 2020. The boundaries of the hippocampus, hippocampus + 5 mm area, hippocampus + 10 mm area, and hippocampus + 20 mm area were delineated, and the distances from the brain metastases to the hippocampus were measured. Univariate and multivariate logistic regressions were adopted to analyze the high-risk factors of hippocampal metastasis.

Results

A total of 3,375 brain metastases in 411 patients were included in the analysis. The metastasis rates in the hippocampus and surrounding areas of the entire group were as follows: 7.3% (30/411) in the hippocampus, 16.5% (68/411) in the hippocampus + 5 mm area, 23.8% (98/411) in the hippocampus + 10 mm area, and 36.5% (150/411) in the hippocampus + 20 mm area. Univariate logistic regression showed that the pathological type, the number of metastases, the maximum diameter of metastases, and the volume of brain metastases were all correlated with hippocampal metastasis. Multivariate logistic regression showed that the pathological type, the number of metastases, and the total volume of metastases were correlated with hippocampal metastasis.

Conclusion

The pathological type, the number of metastases, and the total volume of metastases are the high-risk factors associated with hippocampal metastasis. Small cell lung cancer (SCLC) has a significantly higher rate of hippocampal metastasis than other tumor types. The greater the number and total volume of metastases, the more likely the hippocampal metastasis. For patients with SCLC or a greater number and total volume of brain metastases, the implementation of HA-WBRT may bring a higher risk of tumor recurrence.

Development and validation a radiomics nomogram for diagnosing occult brain metastases in patients with stage IV lung adenocarcinoma

Background

To develop and validate a radiomics model using computed tomography (CT) images acquired from the first diagnosis to estimate the status of occult brain metastases (BM) in patients with stage IV lung adenocarcinoma (LADC).

Methods

One hundred and ninety-three patients who were first diagnosed with stage IV LADC were enrolled and divided into a training cohort (n=135) and a validation cohort (n=58). Then, 725 radiomic features were extracted from contoured primary tumor volumes of LADCs. Intra- and interobserver reliabilities were calculated, and the least absolute shrinkage and selection operator (LASSO) was applied for feature selection. Subsequently, a radiomics signature (Rad-Score) was built. To improve performance, a nomogram incorporating a radiomics signature and an independent clinical predictor was developed. Finally, the established signature and nomogram were assessed using receiver operating characteristic (ROC) curves and precision-recall curves (PRC). Both empirical and α-binomial model-based ROCs and PRCs were plotted, and the area under the curve (AUC) and average precision (AP) of ROCs and PRCs were calculated and compared.

Results

A radiomics signature and Rad-Score were constructed using eight radiomic features, and these had significant correlations with occult BM status. A nomogram was developed by incorporating a Rad-Score and the primary tumor location. The nomogram yielded an optimal AUC of 0.911 [95% confidence interval (CI): 0.903–0.919] and an AP of 0.885 (95% CI: 0.876–0.894) in the training cohort, and an AUC of 0.873 (95% CI: 0.866–0.80) and an AP of 0.827 (95% CI: 0.820–0.834) in the validation cohort using α-binomial model-based method. The calibration curve demonstrated that the nomogram showed high agreement between the actual occult BM probability and predicted by the nomogram (P=0.427).

Conclusions

The nomogram incorporating a radiomics signature and a clinical risk factor achieved optimal performance after holistic assessment using unbiased indexes for diagnosing occult BM of patients who were first diagnosed with stage IV LADC.

Development and Validation of a CT-Based Signature for the Prediction of Distant Metastasis Before Treatment of Non-Small Cell Lung Cancer

RATIONALE AND OBJECTIVES

To develop and validate a radiomics model, a clinical-semantic model and a combined model by using standard methods for the pretreatment prediction of distant metastasis (DM) in patients with non-small-cell lung cancer (NSCLC) and to explore whether the combined model provides added value compared to the individual models.

MATERIALS AND METHODS

This retrospective study involved 356 patients with NSCLC. According to the image biomarker standardization initiative reference manual, we standardized the image processing and feature extraction using in-house software. Finally, 6692 radiomics features were extracted from each lesion based on contrast-enhanced chest CT images. The least absolute shrinkage selection operator and the recursive feature elimination algorithm were used to select features. The logistic regression classifier was used to build the model. Three models (radiomics model, clinical-semantic model and combined model) were constructed to predict DM in NSCLC. Area under the receiver operating characteristic curves were used to validate the ability of the three models to predict DM. A visual nomogram based on the combined model was developed for DM risk assessment in each patient.

RESULTS

The receiver operating characteristic curve showed predictive performance for DM of the radiomics model (area under the curve [AUC] values for training and validation were 0.76 [95% CI, 0.704 - 0.820] and 0.76 [95% CI, 0.653 - 0.858], respectively). The combined model had AUCs of 0.78 (95% CI, 0.723 - 0.835) and 0.77 (95% CI, 0.673 - 0.870) in the training and validation cohorts, respectively. Both the radiomics model and combined model performed better than the clinical-semantic model (0.70 [95% CI, 0.634 - 0.760] and 0.67 [95% CI, 0.554 - 0.787] in the training and validation cohorts, respectively).

CONCLUSION

The radiomics model and combined model may be useful for the prediction of DM in patients with NSCLC.

Brain metastases: the role of clinical imaging

Imaging of brain metastases (BMs) has advanced greatly over the past decade. In this review, we discuss the main challenges that BMs pose in clinical practice and describe the role of imaging.Firstly, we describe the increased incidence of BMs of different primary tumours and the rationale for screening. A challenge lies in selecting the right patients for screening: not all cancer patients develop BMs in their disease course.Secondly, we discuss the imaging techniques to detect BMs. A three-dimensional (3D) T1W MRI sequence is the golden standard for BM detection, but additional anatomical (susceptibility weighted imaging, diffusion weighted imaging), functional (perfusion MRI) and metabolic (MR spectroscopy, positron emission tomography) information can help to differentiate BMs from other intracranial aetiologies.Thirdly, we describe the role of imaging before, during and after treatment of BMs. For surgical resection, imaging is used to select surgical patients, but also to assist intraoperatively (neuronavigation, fluorescence-guided surgery, ultrasound). For treatment planning of stereotactic radiosurgery, MRI is combined with CT. For surveillance after both local and systemic therapies, conventional MRI is used. However, advanced imaging is increasingly performed to distinguish true tumour progression from pseudoprogression.FInally, future perspectives are discussed, including radiomics, new biomarkers, new endogenous contrast agents and theranostics.

Predictive Indicators of Brain Metastasis-Free Survival in Patients With Lung Cancer at a Chinese Cancer Center

Introduction

Metastasis tumors of the brain derive mostly from lung cancer, breast cancer, melanoma, and more commonly among lung cancer patients. Once brain metastasis is diagnosed, the prognosis of untreated patients is shown to be very poor. In this study, we describe the clinical and pathological features of patients with lung cancer at our institution from 2009 to 2021. We also examined factors like gender, type, size, and location of the primary tumor and leukoaraiosis level at the first visit are associated with patients’ brain metastasis-free survival (the time free of brain metastases since the first diagnosis of lung cancer).

Materials and methods

We retrospectively reviewed patients with a final histologic diagnosis of lung cancer from September 2009 to January 2015. The evaluation included history, physical examination, and contrast-enhanced computerized tomography of the chest. Contrast-enhanced magnetic resonance imaging of the head was performed at the first visit and following treatment. The patients’ age, gender, tumor size, histology type, location of the lung tumor, and leukoaraiosis level at the first visit were recorded and correlated to the patients’ brain-metastasis-free survival time.

Results

The study included 68 patients - 39 males and 29 females -with a mean age of 55.15 years (range 35-69 years). Adenocarcinoma was diagnosed in 47 patients (22 males and 25 females), Squamous carcinoma was diagnosed in 12 patients (9 males and 3 females), non-small cell lung carcinoma was diagnosed in 3 patients (2 males and one female), one male patient had the diagnosis of adenosquamous tumor and 1 male patient had the diagnosis of neuroendocrine tumor. Tumor size was <3 cm in 19 patients, 3-5 cm in 29 patients, 5-10 cm in 17 patients, and three other patients’ size was hard to measure. Of the 68 patients, 10 patients were detected as brain metastasis by magnetic resonance imaging at first diagnosis, 22 patients were diagnosed as brain metastasis during the follow-up visits, 36 patients were not found as brain metastasis until the last visit. According to the Cox regression univariate analysis, two factors were correlated to shorter brain metastasis-free survival: Not-squamous lung carcinoma (SCC) and higher location of the tumor. The multivariate statistical analysis correlated two factors to shorter brain metastasis-free survival: non-SCC histology type and age≥62.

Conclusions

In conclusion, we found that SCC had a lower incidence of brain metastasis in patients than other lung cancer types. According to the Cox regression multivariate analysis, age <62 and SCC were two protective factors of brain metastasis. According to the Cox regression univariate and analysis. The lower location of the tumor was the protective factor of brain metastasis. According to the Cox regression univariate analysis, other parameters, such as gender or tumor size, did not have a role in brain metastasis-free survival in these patients.

Clinical Utility of F-18 Labeled Fibroblast Activation Protein Inhibitor (FAPI) for Primary Staging in Lung Adenocarcinoma: a Prospective Study

PURPOSE

The purpose of this study was to compare the primary staging of F-18 labeled fibroblast activation protein inhibitor ([¹⁸F]F-FAPI) with that of F-18 labeled fluordesoxyglucose positron emission tomography/computed tomography ([¹⁸F]F-FDG PET/CT) in patients with lung adenocarcinoma (LAD).

PROCEDURES

We prospectively analyzed the images of LAD patients who underwent [¹⁸F]F-FAPI and [¹⁸F]F-FDG PET/CT between May 2020 and August 2021. [¹⁸F]F-FAPI and [¹⁸F]F-FDG uptakes were compared using the paired samples t test, and lesion numbers were compared using the Wilcoxon signed-rank test.

RESULTS

Thirty-four LAD patients were evaluated. Patients showed high [¹⁸F]F-FAPI uptake in primary lesions (SUVmax 12.54 ± 3.77). Both [¹⁸F]F-FAPI and [¹⁸F]F-FDG had 100% detection rates for primary tumors. However, [¹⁸F]F-FAPI showed higher SUV_max than [¹⁸F]F-FDG in lesions of the lymph nodes, pleura, bones, and other tissues (all P ≤ 0.05). Although the absolute uptake values of [¹⁸F]F-FAPI in brain lesions were lower than those of [¹⁸F]F-FDG (1.56 ± 2.19 vs.7.34 ± 3.54, P < 0.0001), the tumor-to-background (T/B) ratios were significantly higher than those of [¹⁸F]F-FDG (9.53 ± 12.07 vs.1.01 ± 0.49, P < 0.0001). Generally, [¹⁸F]F-FAPI PET/CT could visualize more total lesions than [¹⁸F]F-FDG (554 vs.464, P = 0.003), especially in lymph nodes (258 vs.229, P = 0.039), the brain (34 vs.9, P = 0.002), and pleura (56 vs.30, P = 0.041). However, contrast-enhanced brain magnetic-resonance imaging (MRI) showed more brain lesions than [¹⁸F]F-FAPI PET/CT (56 vs.34, P = 0.002). Compared with the [¹⁸F]F-FDG-based TNM stage, the [¹⁸F]F-FAPI-based TNM stage was upgraded in six patients (17.6%).

CONCLUSIONS

[¹⁸F]F-FAPI PET/CT showed a very high detection rate for primary LAD. In addition, ¹⁸F-FAPI PET/CT demonstrated clearer tumor delineation and more lesions than [¹⁸F]F-FDG PET/CT, especially in lymph nodes, the brain, and pleura. Therefore, [¹⁸F]F-FAPI had an advantage over [¹⁸F]F-FDG for primary staging of LAD. However, brain MRI could identify more and smaller lesions than [¹⁸F]F-FAPI PET/CT.

Factors Associated with Cranial Nerve Injury after Radiotherapy for Large Brain Metastases

This paper mainly studied the correlation factors of cranial nerve injury after radiotherapy for large brain metastases by investigating the influencing factors and predictors of cranial nerve injury, which can provide a good reference and idea for radiotherapy. Through a large number of experiments, it is proved that the research idea proposed in this paper is reasonable and correct.

Survival Outcomes of Local Compared With Systemic First Treatment of Non-Small Cell Lung Cancer Brain Metastases

OBJECTIVE

This retrospective study evaluated the survival advantage of local treatment targeted to brain metastases, relative to systemic therapy, as the first option for brain metastases of non-small cell lung cancer (NSCLC).

METHODS

First reviewed were 291 cases of NSCLC brain metastases from two centers. All patients were at least 18 years old, with histologically confirmed NSCLC, and required and underwent both local (radiotherapy or brain surgery) and systemic treatment (chemotherapy and tyrosine kinase inhibitor [TKI] medication). Demographics, clinical characteristics, and treatment-related variables were collected.

RESULTS

The final population comprised 160 patients. Overall, the multivariate analysis suggested that the following were associated with better survival: >3 cycles of chemotherapy; stereotactic radiosurgery; and TKI medication (all, P = 0.000). Local treatment that began within 1 week of the diagnosis of brain metastases was associated with poorer survival (P = 0.006). Among the 111 patients with symptomatic brain metastases, the multivariate analysis indicated that better survival was associated with >3 cycles of chemotherapy (P = 0.000), radiation dose >40 Gy (P = 0.001), stereotactic radiosurgery (P = 0.000), and TKI medication (P = 0.000), while local treatment that began within 1 week after the diagnosis of brain metastases was associated with poorer survival (P = 0.015).

CONCLUSIONS

For patients with NSCLC brain metastases, regardless of the presence of clinical symptoms associated with brain metastases, systemic treatment before local may be better for survival. Even when used to relieve clinical symptoms, local treatment should be within a setting of sufficient systemic treatment.

Central Nervous System Metastases

The proportion of patients developing central nervous system (CNS) metastasis is increasing. Most are identified once symptomatic. Surgical resection is indicated for solitary or symptomatic brain metastases, separation surgery for compressive radioresistant spinal metastases, and instrumentation for unstable spinal lesions. Surgical biopsies are performed when histological diagnoses are required. Stereotactic radiosurgery is an option for limited small brain metastases and radioresistant spinal metastases. Whole-brain radiotherapy is reserved for extensive brain metastases and leptomeningeal disease with approaches to reduce cognitive side effects. Radiosensitive and inoperable spinal metastases typically receive external beam radiotherapy. Systemic therapy is increasingly being utilized for CNS metastases.

Response and safety of whole-brain radiotherapy plus temozolomide for patients with brain metastases of non-small-cell lung cancer: A meta-analysis

Objective

The aim of the present work was to investigate the response and safety of whole‐brain radiotherapy (WBRT) plus temozolomide (TMZ) for patients with brain metastases of non‐small‐cell lung cancer (NSCLC).

Methods

The electronic databases of Pubmed, EMbase, Cochrane, Wangfang, china national knowledge infrastructure (CNKI), and Google scholar were systematically searched to identify the prospective randomized trials relevant to WBRT plus TMZ for patients with brain metastases of NSCLC. The data associated with treatment response and toxicity were extracted from original included studies. The relative risk (RR) for treatment response and toxicity between WBRT+TMZ and WBRT alone was pooled by fixed or random effect model. Publication bias was investigated by Begg's funnel plot and Egger's line regression test.

Results

Twenty‐five clinical trials fulfilled the inclusion criteria and were included in the meta‐analysis. The pooled results showed WBRT+TMZ can significant improve the objective response rate (ORR) compared with WBRT alone (RR = 1.43, 95% confidence interval [CI] 1.32–1.55, p < 0.05) under a fixed effect model. WBRT+TMZ significantly increased the III–IV hematological toxicity compared to WBRT alone (RR = 1.66, 95% CI 1.12–2.54, p < 0.05) in the fixed effect model. Grade III–IV gastrointestinal toxicity was increased in WBRT+TMZ compared to WBRT alone (RR = 1.72, 95% CI 1.29–2.30, p < 0.05). Begg's funnel plot and Egger's line regression test indicated publication bias.

Conclusion

Based on the present work, WBRT+TMZ can improve the ORR for brain metastases of NSCLC, but the risk of treatment‐associated grade III/IV hematological toxicity and gastrointestinal toxicity were also increased compared to WBRT alone.

Research Progress and Challenges in the Treatment of Central Nervous System Metastasis of Non-Small Cell Lung Cancer

Non-small cell lung cancer (NSCLC) is one of the most common malignant tumors and has high morbidity and mortality rates. Central nervous system (CNS) metastasis is one of the most frequent complications in patients with NSCLC and seriously affects the quality of life (QOL) and overall survival (OS) of patients, with a median OS of untreated patients of only 1-3 months. There are various treatment methods for NSCLC CNS metastasis, including surgery, chemotherapy, radiotherapy, targeted therapy, and immunotherapy, which do not meet the requirements of patients in terms of improving OS and QOL. There are still many problems in the treatment of NSCLC CNS metastasis that need to be solved urgently. This review summarizes the research progress in the treatment of NSCLC CNS metastasis to provide a reference for clinical practice.

Metastatic patterns and prognosis of young lung cancer patients: a population-based study by age

Background

We aimed to examine the different metastatic patterns and corresponding survival outcomes between all ages of young (aged <60 years) and elderly lung cancer patients.

Methods

Lung cancer patients from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2015 were divided into a young and elderly group. The young group was subdivided into four consecutive subgroups. Baseline characteristics were analyzed by the Chi-square test. Survival differences were evaluated by Kaplan-Meier curves and Cox proportional hazards models.

Results

Of the total 200,362 lung cancer patients, 155,348 were elderly patients and 45,014 were young patients, including 3,461 aged <45 years, 5,697 aged 45–49 years, 13,645 aged 50–54 years, and 22,211 aged 55–59 years. Compared with elderly lung cancer patients, extrathoracic metastases were significantly more frequent in each younger group, irrespective of the site and number of extrathoracic metastatic organs. Regardless of metastasis patterns, young ages were independent prognostic factors of lung cancer-specific survival (LCSS) [<45 years: hazard ratio (HR): 0.70; 45–49 years: HR: 0.87; 50–54 years: HR: 0.90; 55–59 years: HR: 0.93, all P values were <0.001]. In each age subgroup, patients with multi-organ extrathoracic metastasis had the worst LCSS.

Conclusions

Young lung cancer patients across all ages were at increased risk of extrathoracic metastasis, especially multi-organ patterns, but had a reduced risk of lung cancer-related death compared to elderly patients. Regular and meticulous monitoring of potential metastasized organs is required in young lung cancer patients throughout the follow-up period.

Epidemiology of Brain Metastases

Brain metastasis continues to be a devastating complication of systemic malignancy, affecting approximately 20% of all patients suffering from cancer. Despite being a major source of morbidity and mortality for this patient population, a nationwide, systematic mechanism for reporting of brain metastases does not exist. Better understanding the epidemiology of brain metastases will help identify individuals who are at greatest risk of developing them and guide clinicians in selecting patients who are most likely to benefit from brain metastasis surveillance and prophylaxis.

The incidence, risk factors and predictive nomograms for early death of lung cancer with synchronous brain metastasis: a retrospective study in the SEER database

BACKGROUND

The prognosis of lung cancer with synchronous brain metastasis (LCBM) is very poor, and patients often die within a short time. However, little is known about the early mortality and related factors in patients with LCBM.

METHODS

Patients diagnosed with LCBM between 2010 and 2016 were enrolled from the Surveillance, Epidemiology, and End Result (SEER) database. Univariate and multivariate logistic regression analysis were used to identify significant independent prognostic factors, which were used to construct nomograms of overall and cancer-specific early death. Then, the prediction ability of the model was verified by receiver operating characteristic (ROC) curve. At last, the clinical application value of the model was tested through decision curve analysis (DCA).

RESULTS

A total of 29,902 patients with LCBM were enrolled in this study. Among them, 13,275 (44.4%) patients had early death, and 11,425 (38.2%) cases died of lung cancer. The significant independent risk factors for overall and cancer-specific early death included age, race, gender, Gleason grade, histological type, T stage, N stage, bone metastasis, liver metastasis and marital status, which were used to construct the nomogram. The ROC curve demonstrated good predictive ability and clinical application value. The areas under the curve (AUC) of the training group was 0.793 (95% CI: 0.788-0.799) and 0.794 (95% CI: 0.788-0.799), in the model of overall and cancer-specific early death respectively. And the AUC of the validation group were 0.803 (95% CI: 0.788-0.818) and 0.806 (95% CI: 0.791-0.821), respectively. The calibration plots of the model showed that the predicted early death is consistent with the actual value. The DCA analysis indicated a good clinical application value of this model.

CONCLUSIONS

We established a comprehensive nomogram to predict early death in lung cancer patients with synchronous brain metastases. Nomograms may help oncologists develop better treatment strategies, such as clinical trials and hospice care.

Socioeconomic Disparities in Non-Small Cell Lung Cancer With Brain Metastases at Presentation: A Population-Based Study

OBJECTIVE/BACKGROUND

The purpose of this study was to characterize the impact of household income disparities in the survival of patients with non-small cell lung cancer (NSCLC) presenting with brain metastasis on a population-based level.

METHODS

This is a population-based cohort study using the Surveillance, Epidemiology, and End Results (SEER) database from 2010-2016 including 15,808 NSCLC patients presenting with brain metastasis.

RESULTS

This study comprises 15,808 adult patients with NSCLC presenting with brain metastases having an age range 64 ± 10 years with 51% male, 76% white, 52% married, 61% insured, and with 85% of lung adenocarcinoma histopathology. The 1-, 2- and 5-year survival rates for living in the lower household income quartile were 21%, 10%, and 3%, respectively, for the second quartile 24%, 10%, and 3%; for the third quartile 28%, 14%, and 4%; and for the top quartile 31%, 17%, and 4%, respectively. Multivariate Cox proportional hazard analysis showed that living in a higher quartile household income county is associated with increased survival (P < 0.0001), hazard ratio 0.87, 95% confidence interval (0.82-0.92).

CONCLUSIONS

This population-based study suggests that living in higher median household income counties is associated with increased survival time and reduced risk of mortality for patients with NSCLC who have brain metastases present at diagnosis, independent of other factors. These findings underscore the importance of ensuring adequate and easy access to care for all patients, irrespective of their economic background.

Impact of Low-Dose Computed Tomography Screening for Primary Lung Cancer on Subsequent Risk of Brain Metastasis

INTRODUCTION

Brain metastasis (BM) is one of the most common metastases from primary lung cancer (PLC). Recently, the National Lung Screening Trial revealed the efficacy of low-dose computed tomography (LDCT) screening on LC mortality reduction. Nevertheless, it remains unknown if early detection of PLC through LDCT may be potentially beneficial in reducing the risk of subsequent metastases. Our study aimed to investigate the impact of LDCT screening for PLC on the risk of developing BM after PLC diagnosis.

METHODS

We used the National Lung Screening Trial data to identify 1502 participants who were diagnosed with PLC in 2002 to 2009 and have follow-up data for BM. Cause-specific competing risk regression was applied to evaluate an association between BM risk and the mode of PLC detection-that is, LDCT screen-detected versus non-LDCT screen-detected. Subgroup analyses were conducted in patients with early stage PLC and those who underwent surgery for PLC.

RESULTS

Of 1502 participants, 41.4% had PLC detected through LDCT screening versus 58.6% detected through other methods, for example, chest radiograph or incidental detection. Patients whose PLC was detected with LDCT screening had a significantly lower 3-year incidence of BM (6.5%) versus those without (11.9%), with a cause-specific hazard ratio (HR) of 0.53 (p = 0.001), adjusting for age at PLC diagnosis, PLC stage, PLC histology, and smoking status. This significant reduction in BM risk among PLCs detected through LDCT screening persisted in subgroups of participants with early stage PLC (HR = 0.47, p = 0.002) and those who underwent surgery (HR = 0.37, p = 0.001).

CONCLUSIONS

Early detection of PLC using LDCT screening is associated with lower risk of BM after PLC diagnosis on the basis of a large population-based study.

Epidermal Growth Factor Receptor Mutation Status and Response to Tyrosine Kinase Inhibitors in Advanced Chinese Female Lung Squamous Cell Carcinoma: A Retrospective Study

Background

The frequency of epidermal growth factor receptor (EGFR) mutations and the efficacy of tyrosine kinase inhibitor (TKI) in Chinese female patients with lung squamous cell carcinoma (SCC) are unknown. This study was designed to investigate the incidence of EGFR mutations and the role of targeted therapy in advanced Chinese female lung SCC patients.

Methods

Advanced female patients diagnosed with lung SCC at the Shanghai Chest Hospital between January 2013 and December 2018 were retrospectively analyzed.

Results

A total of 4223 advanced lung SCC patients were screened, and there were 154 female lung SCC patients who had underwent EGFR mutation detection. Positive EGFR mutations were found in 29.9% (46/154) of female lung SCC patients, including twenty-three 19del mutation (14.9%), twenty-one 21L858R mutation (13.6%) and other mutations (1.4%, 21861Q and 20ins). For 45 EGFR positive mutation female SCC patients, the median progression-free survival (PFS) of patients who received EGFR-TKI therapy (n=38) was 8.0 months (95% CI, 5.4-10.7 months), which was significantly longer than patients who were treated with chemotherapy (8.0 vs. 3.2 months, p=0.024), and the median overall survival (OS) was also longer (24.9 months vs. 13.9 months, p=0.020). The objective response rate (ORR) was 44.7% (17/38), and the disease control rate (DCR) was 81.6% (31/38). For 105 female SCC patients with EGFR negative mutation, the median OS was 18.6 months (95% CI, 14.2-22.9 months) and it was no different from that of EGFR positive mutation patients (18.6 vs. 22.8 months, p=0.377).

Conclusion

For advanced Chinese female lung SCC patients with EGFR positive mutations, targeted therapy could confer longer PFS and OS than chemotherapy, but the survival was similar with patients who were negative EGFR mutations.

The Management of Brain Metastases-Systematic Review of Neurosurgical Aspects

Simple Summary

In this comprehensive review, we focused on the neurosurgical treatment as an integrative part of the challenging multidisciplinary management of cerebral metastases, a neuro-oncologic entity, which has been observed to have an increased incidence over the last years. In selected cases, the surgical removal of the space-occupying mass reduces the intracranial pressure, normalizes the metabolic environment, reduces the symptom burden, and allows for the intensification of local and systemic adjuvant treatment. In detail, we discuss the incidence of brain metastases, the role of surgical resection, as well as the evolution of current neurosurgical techniques, the surgical morbidity and mortality of single and multiple lesions, and we enlighten the role of surgery for recurrent tumors.

Abstract

The multidisciplinary management of patients with brain metastases (BM) consists of surgical resection, different radiation treatment modalities, cytotoxic chemotherapy, and targeted molecular treatment. This review presents the current state of neurosurgical technology applied to achieve maximal resection with minimal morbidity as a treatment paradigm in patients with BM. In addition, we discuss the contribution of neurosurgical resection on functional outcome, advanced systemic treatment strategies, and enhanced understanding of the tumor biology.